Patient Scholarship Fund

What It Is

As part of our ongoing efforts to heal as many people as possible, we’ve created the Rising Health Patient Scholarship Fund. This scholarship fund will go towards those who are in need of our services but not in a financial position to do so.

How To Apply

We invite anyone in need to apply for this scholarship, and our clinic will thoughtfully vote on who will receive the funds. Anyone who wishes to contribute to this fund can do so at the end of their appointments here at the clinic. Thank you!

No out-of-state clients shall apply
No non-established clients may apply. The patient must have their first appointment and receive a treatment plan.
No lab costs shall be subject to hardship.

Income Qualifications

Financial Hardship Application Form

Rising Health Specialty Clinic locations abide by the contractual and legal obligations of health benefit plans to collect charges, co-pays, coinsurance, and deductible amounts owed by patients. Recognizing that circumstances may arise where an individual is unable to pay in full at the time of service, we have adopted a policy of screening requests for discounts, delayed payment plans, or forgiveness of debt based on individual circumstances. To do this, we must ask for certain financial information. All information will be held confidential according to our privacy policy. Please provide the documents listed below for each adult family member, and complete this form to the best of your ability. Thank you!

Thank you for reaching out to apply for Rising Health’s hardship assistance. We understand that healthcare costs can sometimes be challenging, and we are committed to helping patients who need additional financial support. Our hardship application is designed to offer assistance to those who meet specific criteria, and we want to ensure you have a clear understanding of how the process works.

Please take note of the following rules for scholarship usage:

Established Patient Requirement: To be eligible for hardship assistance, you must first be an established patient of Rising Health. This means you must have completed a new patient appointment with one of our providers.
Appointment Coverage: Please note that appointments with providers are not covered under our scholarship funding. The scholarship program is intended for other services and treatments outside of direct appointments with our practitioners.
Case-by-Case Consideration: All scholarship applications are carefully reviewed by a committee on a case-by-case basis. The availability of funds at any given time will also affect the outcome of your application.
Equitable Application Process: Scholarships are awarded based on an equitable application process, ensuring fairness to all applicants. You must meet certain financial thresholds to qualify for hardship assistance. These criteria will be reviewed as part of your application.

We encourage you to complete the application thoroughly, providing all required documentation to help us assess your eligibility. Our goal is to support you in accessing the care you need, and we appreciate your understanding of the guidelines that allow us to maintain fairness and sustainability in our scholarship program.

If you have any questions about the application or process, please don’t hesitate to contact our office.

Patient Information

Patient First Name(Required)

Patient Last Name(Required)

Date Of Birth(Required)

Email(Required)

Phone(Required)

Type of assistance requested(Required)

Number of dependents in household(Required)

Employment Information

Current employer(Required)

Employer phone number(Required)

Employer address(Required)

Street Address City State ZIP Code

If unemployed, please state when employment was terminated. If lay-off is temporary, indicate expected duration:

Assistance Received

State financial assistance: Monthly income (after payroll deductions)

Monthly expenses (not including payroll deductions)

Medical expenses for previous calendar year

Please upload a copy of last year’s federal tax return

Drop files here or

Max. file size: 15 MB, Max. files: 1.

Please upload copies of the two most recent payroll stubs or unemployment benefit payments

Drop files here or

Max. file size: 15 MB, Max. files: 2.

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By signing below, I certify that this information is true and complete. I grant this office permission to verify the information, and I acknowledge that completion of this form does not guarantee discount, payment plan or forgiveness of debt.

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